Integration of a clinical pharmacist workforce into newly forming primary care networks: a qualitatively driven, complex systems analysis

Objective The introduction of a new clinical pharmacist workforce via Primary Care Networks (PCNs) is a recent national policy development in the National Health Service in England. This study elicits the perspectives of people with responsibility for local implementation of this national policy package. Attention to local delivery is necessary to understand the contextual factors shaping the integration of the new clinical pharmacy workforce, and thus can be expected to influence future role development. Design A qualitative, interview study Setting and participants PCN Clinical Directors and senior pharmacists across 17 PCNs in England (n=28) Analysis Interviews were transcribed, coded and organised using the framework method. Thematic analysis and complex systems modelling were then undertaken iteratively to develop the themes. Results Findings were organised into two overarching themes: (1) local organisational innovations of a national policy under conditions of uncertainty; and (2) local multiprofessional decision-making on clinical pharmacy workforce integration and initial task assignment. Although a phased implementation of the PCN package was planned, the findings suggest that processes of PCN formation and clinical pharmacist workforce integration were closely intertwined, with underpinning decisions taking place under conditions of considerable uncertainty and workforce pressures. Conclusions National policy decisions that required General Practitioners to form PCNs at the same time as they integrated a new workforce risked undermining the potential of both PCNs and the new workforce. PCNs require time and support to fully form and integrate clinical pharmacists if successful role development is to occur. Efforts to incentivise delivery of PCN pharmacy services in future must be responsive to local capacity.

Methods section -I feel this needs a bit more detail about the qualitative approach and research paradigm -Can more information be provided on how participants were identified (you mention opportunistic sampling and snowballing but how to you know who to contact and did what social media did you use?), what information was sent and at what point did you gain consent? -Page 7, line 6. Did TM and MM carry out the interviews together or separately? -Can you please say some more about complex systems modelling. For someone who is not familiar with this, it would be important to know how it is used and justify why you are using it.
-NVIVO vs NVivo -Page 7, line 22. Spell out PPI Overall the paper is well written and i have no comments regarding the results and discussion.

REVIEWER
Wilson, Tim Oxford Centre for Triple Value Healthcare REVIEW RETURNED 12-Jul-2022

GENERAL COMMENTS
Page 4 Future studies would benefit from interviewing other general practice staff (e.g. receptionists, practice managers and practice nurses) There is a risk of group think as it is highly likely that interviewees had been sharing views prior to the study.

Page5
Line 11-Gatekeeper is an overused and rather simplistic term leading to a misunderstanding of what a GP does. Starfield uses a better term-coordinator of care. The authors are perhaps too young to recall that pharmacists were employed by GP fundholders for medicines optimisation. Page 6 Sections b) and c)-the authors omit to mention where these interviewees were working. Lines 42 and 48-the editors will need to decide whether the very opportunistic and pragmatic approach to sampling is a barrier to publication. I do not believe that the data gleaned would have been different had the sampling technique been more structured. Personally, I did not find the graphic on page 19 helpful. It could be simplified. The discussion would benefit from being more focused, it is a bit woolly at present, it is not clear how the findings are being used to direct the discussion and implications both of which would also benefit from more systematic structuring around existing literature. For example, the governance implications are sensible but it's not clear how you've got from your findings to this. The last two sentences in the governance implications are both rather speculative and again bear no obvious relation to what has come before.

VERSION 1 -AUTHOR RESPONSE
Reviewer: 1 Dr. Nilesh Patel, University of Reading Comments to the Author: Thank you for providing a timely and very interesting article on the clinical pharmacy workforce integration within PCN's. This is an important area to research and inform policy makers and PCN workforce about. There are some areas that need clarification. These are fairly minor but I hope will add further clarity to the article.
Methods section -I feel this needs a bit more detail about the qualitative approach and research paradigm -Thankswe have responded to your specific points and feel this has strengthened our presentation of the approach we took -Can more information be provided on how participants were identified (you mention opportunistic sampling and snowballing but how to you know who to contact and did what social media did you use?), what information was sent and at what point did you gain consent? -We now describe this in greater detail -Page 7, line 6. Did TM and MM carry out the interviews together or separately? Separatelywe now note this.
-Can you please say some more about complex systems modelling. For someone who is not familiar with this, it would be important to know how it is used and justify why you are using it. Thankswe now provide detail of the complex systems approach when outlining the research question at the end of the introduction. There is a risk of group think as it is highly likely that interviewees had been sharing views prior to the study. Thankswe now mention,n the strengths and limitations section, that broadening out to include other general practice staff would allow exploration of diverse perspectives and multidisciplinary working. Page5 Line 11-Gatekeeper is an overused and rather simplistic term leading to a misunderstanding of what a GP does. Starfield uses a better term-coordinator of care. We now refer to GP's role of coordinating patient care. The authors are perhaps too young to recall that pharmacists were employed by GP fundholders for medicines optimisation. We now include mention of the GP Fundholding scheme. Page 6 Sections b) and c)-the authors omit to mention where these interviewees were working. We now include a separate sentence describing where the interviewees were recruited.
Lines 42 and 48-the editors will need to decide whether the very opportunistic and pragmatic approach to sampling is a barrier to publication. I do not believe that the data gleaned would have been different had the sampling technique been more structured. Personally, I did not find the graphic on page 19 helpful. It could be simplified. The development of the model was an integral part of the analytic process and involved input from senior stakeholders and PPI representatives. We do not think it can be simplified without obscuring the complexity of PCN policy implementation. Furthermore, we have included detailed, written findings in the themes so that readers can read them if they do not find the model helpful. We also note Reviewer 3's comment that it "conveys the complexity well".
Reviewer: 3 Dr. Simon Bailey, University of Kent Comments to the Author: BMJ Open review 18/7/22 This is a very clearly written and warranted paper that looks at integrating clinical pharmacists into newly forming primary care networks, which is an important issue around the objectives and implementation of the policy as well as the longer term aim of diversifying the primary care workforce. For the most part the paper is well presented and well argued, however, it is let down by discussion, which needs to demonstrate how it develops the findings presented as well as existing literature. Thanksthis has been extremely helpful to the literature review aspect of the paper. We have incorporated a new paragraph in the introduction that summarises the articles you have suggested. Methods.
In the datasets b) and c) it isn't clear where these PCNs were or if there was overlap with those involved as part of a). Reading on this detail is provided below but it would be clearer to include it within the description of each. I really like the attempt to visualise the findings related to the emerging policythis conveys the complexity well. Thank you Discussion The discussion would benefit from being more focused, it is a bit woolly at present, it is not clear how the findings are being used to direct the discussion and implications both of which would also benefit from more systematic structuring around existing literature. For example, the governance implications are sensible but it's not clear how you've got from your findings to this. The last two sentences in the governance implications are both rather speculative and again bear no obvious relation to what has come before. Thanks -We have grounded the discussion more fully in the findings and existing literature throughout. For example, the governance implications paragraph has been amended to focus more centrally on the issue of the contractual nature of PCNs and the employment of the clinical pharmacists. To avoid this appearing speculative, the final sentence highlights implications for clinical pharmacist integration and role development.

REVIEWER
Bailey, Simon University of Kent, Centre for Health Services Studies REVIEW RETURNED 28-Sep-2022

GENERAL COMMENTS
Thank you for your attention to revisions. I believe this is a useful addition to the literature and have no further suggestions for changes.